NIHSS Best Gaze 3 — Questions and Answers
Question 1: A patient reports a prior history of an isolated sixth nerve (abducens) palsy from an old injury unrelated to the current stroke. How should the examiner handle this during NIHSS Best Gaze scoring?
- Score as 0 since it is pre-existing
- Score as 2 since gaze is abnormal
- Score based only on findings attributable to the acute stroke (Correct answer)
- The item cannot be scored
Correct answer: Score based only on findings attributable to the acute stroke
NIHSS instructions direct the examiner to score only deficits attributable to the acute stroke, not pre-existing conditions.
Question 2: Which of the following conditions can cause a score of 2 on the NIHSS Best Gaze item?
- Isolated internuclear ophthalmoplegia (INO)
- Mild slowing of saccades in one eye
- Horizontal forced deviation uncorrectable by oculocephalic maneuver (Correct answer)
- Incomplete but present horizontal movement
Correct answer: Horizontal forced deviation uncorrectable by oculocephalic maneuver
A score of 2 requires forced deviation or total gaze paresis not overcome by the oculocephalic maneuver.
Question 3: In the NIHSS, Best Gaze item, what is the maximum possible score?
- 1
- 2 (Correct answer)
- 3
- 4
Correct answer: 2
The Best Gaze item is scored 0–2, making 2 the maximum.
Question 4: A patient with a right hemisphere stroke demonstrates conjugate gaze deviation toward the lesion (right). This is an example of:
- Contralateral gaze deviation
- Ipsilateral gaze deviation (Correct answer)
- Vertical gaze palsy
- Internuclear ophthalmoplegia
Correct answer: Ipsilateral gaze deviation
Hemispheric strokes typically cause ipsilateral (toward-the-lesion) conjugate gaze deviation because the hemisphere drives gaze to the contralateral side.
Question 5: A posterior fossa (brainstem) stroke is more likely than a hemispheric stroke to cause gaze deviation in which direction?
- Toward the lesion side
- Away from the lesion side (contralateral) (Correct answer)
- Purely vertical
- No gaze deviation
Correct answer: Away from the lesion side (contralateral)
Pontine lesions injure horizontal gaze centers and often cause deviation away from the lesion (contralateral), opposite to supratentorial strokes.
Question 6: A patient cannot cooperate with voluntary horizontal gaze testing due to severe aphasia. The examiner rotates the patient's head. The eyes deviate conjugately to the left when the head turns right. What does this finding indicate?
- Total gaze paresis — score 2
- Intact oculocephalic reflex — helps verify voluntary gaze capacity (Correct answer)
- Forced deviation to the left — score 2
- Vertical gaze palsy — score 1
Correct answer: Intact oculocephalic reflex — helps verify voluntary gaze capacity
Conjugate eye movement opposite to head turn indicates an intact oculocephalic (doll's eye) reflex, meaning the brainstem gaze circuitry is preserved.
Question 7: Which item on the NIHSS specifically captures deficits in vertical gaze?
- Best Gaze (item 2)
- Visual fields (item 3)
- Facial palsy (item 4)
- Vertical gaze is not separately scored on the NIHSS (Correct answer)
Correct answer: Vertical gaze is not separately scored on the NIHSS
The NIHSS Best Gaze item tests only horizontal movements; vertical gaze deficits are not captured by any dedicated NIHSS item.
NIHSS Best Gaze 3
A patient reports a prior history of an isolated sixth nerve (abducens) palsy from an old injury unrelated to the current stroke.
How should the examiner handle this during NIHSS Best Gaze scoring?